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Menopause

Menopause is the time in a woman's life when her periods (menstruation) stop. Most often, it is a natural, normal body change that most often occurs between ages 45 to 55. After menopause, a woman can no longer become pregnant.

Alternative Names

Perimenopause; Postmenopause

Causes

During menopause, a woman's ovaries stop making eggs. The body produces less of the female hormones estrogen and progesterone. Lower levels of these hormones cause menopause symptoms.

Periods occur less often and eventually stop. Sometimes this happens suddenly. But most of the time, periods slowly stop over time.

Menopause is complete when you have not had a period for 1 year. This is called postmenopause. Surgical menopause takes place when surgical treatments cause a drop in estrogen. This can happen if your ovaries are removed.

Menopause can also sometimes be caused by drugs used for chemotherapy or hormone therapy (HT) for breast cancer.

ou're a woman nearing middle age. It's that time in your life when your periods are starting to stop and your body is going through changes. You may be starting to have hot flashes that you've heard about before. Could menopause be around the corner?So, what is menopause?Menopause typically happens to women somewhere around the ages of 45 to 55. During menopause, your ovaries stop making eggs and produce less estrogen and progesterone, hormones that play a vital role in pregnancy and how your body uses calcium and maintains healthy cholesterol levels, among other things. Changes in these hormones cause menopause symptoms. You will often begin having fewer periods, and eventually they stop. Menopause is complete when you have not had a period for over a year. Women who are post-menopausal can no longer get pregnant without a donor egg. Symptoms can vary from woman to woman. And these symptoms may last 5 or more years. Also, some women have worse symptoms than others. The first thing you may notice is that your periods start to change. They might occur more often or less often. Some women get their period every 3 weeks during menopause. These changes may last several years before periods completely stop.Other common symptoms include your heart pounding or racing, hot flashes, night sweats, skin flushing, and problems sleeping. You may have a decreased interest in sex, develop forgetfulness, have headaches, and suffer from mood swings, and have vaginal dryness and painful sexual intercourse.Treatment for menopause depends on many things, including how bad your symptoms are, your overall health, and your preference. It may include lifestyle changes or hormone therapy.Hormone therapy may help if you have severe hot flashes, night sweats, mood problems, or vaginal dryness. Hormone therapy is treatment with estrogen and, sometimes, progesterone. Talk to your doctor about the benefits and risks of hormone therapy. Hormone therapy may increase your risk of developing breast cancer, heart attacks, strokes, and blood clots. Topical hormone therapy has some of the benefits and fewer of the risks.Your doctor can tell you about other options besides taking hormones, including antidepressants, a blood pressure medicine called clonidine, and Gabapentin, a seizure drug that can help reduce hot flashes.Lifestyle changes may help in reducing your menopause symptoms, though it's not been proven. You might consider trying to avoid caffeine, alcohol, and certain spicy foods. Or to try eating soy foods and other legumes, because they contain fitoestrogens. You'll want to remember to get plenty of calcium and vitamin D in your food or supplements, and plenty of exercise especially during this time. Consider Kegel exercises every day to strengthen the muscles of the vagina and pelvis. Practice slow, deep breathing if you feel a hot flash coming on. Yoga, tai chi, or meditation may also helpful.After menopause, you may be at risk for bone loss, higher cholesterol, and heart disease, so make sure you work with your doctor to manage or even prevent these problems.

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Symptoms

Symptoms vary from woman to woman. They may last 5 or more years. Symptoms may be worse for some women than others. Symptoms of surgical menopause can be more severe and start more suddenly.

The first thing you may notice is that periods start to change. They might occur more often or less often. Some women might get their period every 3 weeks before starting to skip periods You may have irregular periods for 1 to 3 years before they stop completely.

Menopause is the transition in a woman's life when the ovaries stop releasing eggs, menstrual activity decreases and eventually ceases, and the body decreases the production of the female hormones estrogen and progesterone.

Common symptoms of menopause include:

  • Menstrual periods that occur less often and eventually stop
  • Heart pounding or racing
  • Hot flashes, usually worst during the first 1 to 2 years
  • Night sweats
  • Skin flushing
  • Sleeping problems (insomnia)

Other symptoms of menopause may include:

  • Decreased interest in sex or changes in sexual response
  • Forgetfulness (in some women)
  • Headaches
  • Mood swings including irritability, depression, and anxiety
  • Urine leakage
  • Vaginal dryness and painful sexual intercourse
  • Vaginal infections
  • Joint aches and pains
  • Irregular heartbeat (palpitations)

Exams and Tests

Blood and urine tests can be used to look for changes in hormone levels. Test results can help your health care provider determine if you are close to menopause or if you have already gone through menopause.

Tests that may be done include:

  • Estradiol
  • Follicle-stimulating hormone (FSH)
  • Luteinizing hormone (LH)

Your provider will perform a pelvic exam. Decreased estrogen can cause changes in the lining of the vagina.

Bone loss increases during the first few years after your last period. Your provider may order a bone density test to look for bone loss related to osteoporosis. This bone density test is recommended in all women over age 65. This test may be recommended sooner if you are at higher risk for osteoporosis because of your family history or medicines that you take.

If you've ever watched an apartment or office building under construction, you've seen the metal scaffolding that keeps the building standing upright. Inside your body, bones are the scaffolding that keep you standing upright. As you get older, these supports can weaken. And if they get too weak, you could wind up with a fracture. Let's talk about the bone-thinning condition called osteoporosis.Your internal scaffolding was built when you were young. Calcium and other minerals helped strengthen your bones, provided that you got enough of them from your diet. As you get older, those minerals can start to leech out of your bones, leaving them brittle, fragile, and easily breakable, a condition known as osteoporosis. Women over 50 are especially at risk for osteoporosis because during menopause they lose estrogen, which helps to keep bones strong.The tricky part about osteoporosis is that it's hard to tell you have it. You may not have any symptoms until you've already fractured a bone. Getting a bone density scan, which measures bone thickness, is one way to find out whether you have osteoporosis so you can start treatment right away if you need it. To keep your bones strong, try to get at least 1,200 milligrams of calcium daily, paired with 1,000 international units of vitamin D, which helps your body absorb calcium. You can eat foods that are high in these nutrients, like frozen yogurt, salmon, and low-fat milk, or, if you're not a big fan of fish or dairy, you can take supplements.Weight bearing exercise is also your ally when it comes to strengthening bones. A combination of weight bearing exercises like walking or playing tennis, plus strength training and balance exercises will reduce your risk of getting a fracture if you fall. You will want to get at least thirty minutes of exercise three times a week to see the benefits. And, stop smoking. Cigarette smoke both accelerates bone loss and blocks treatments from being as affective.If you've been diagnosed with osteoporosis, your doctor may recommend drugs called bisphosphonates to prevent further bone damage. Other medicines, including calcitonin, parathyroid hormone, and raloxifene are also treatment options.Don't let bone loss get so far along that you could have a disabling fracture from a minor fall. Start strengthening your bones with diet and exercise while you're still young. As you get older, talk to your doctor about bone density scans, and ask whether you need to take medicine if you're at risk for, or are starting to show signs of osteoporosis. And if your bones aren't as strong as they used to be, avoid falls by wearing shoes that fit well, and clearing clutter on the floor before it can trip you up, and bring you down.

Treatment

Treatment may include lifestyle changes or HT. Treatment depends on many factors such as:

  • How bad your symptoms are
  • Your overall health
  • Your preferences

HORMONE THERAPY

HT may help if you have severe hot flashes, night sweats, mood issues, or vaginal dryness. HT is treatment with estrogen and, sometimes, progesterone.

Talk to your provider about the benefits and risks of HT. Your provider should be aware of your entire medical and family history before prescribing HT.

Several major studies have questioned the health benefits and risks of HT, including the risk of developing breast cancer, heart attacks, strokes, and blood clots.

Current guidelines support the use of HT for the treatment of hot flashes. Specific recommendations:

  • HT may be started in women who have recently entered menopause.
  • HT should not be used in women who started menopause many years ago, except for vaginal estrogen treatments.
  • The medicine should not be used for longer than necessary.
  • Women taking HT should have a low risk for stroke, heart disease, blood clots, or breast cancer.

To reduce the risks of estrogen therapy, your provider may recommend:

  • A lower dose of estrogen or a different estrogen preparation (for instance, a vaginal cream or skin patch rather than a pill)
  • Frequent and regular physical exams, including breast exams and mammograms
A mammogram is an x-ray picture of the breasts. It is used to find tumors and to help tell the difference between noncancerous (benign) and cancerous (malignant) disease. One breast at a time is rested on a flat surface that contains the x-ray plate. A device called a compressor is pressed firmly against the breast to help flatten out the breast tissue. Each breast is compressed horizontally,then obliquely and an x-ray is taken of each position.

Women who still have a uterus (that is, have not had surgery to remove it for any reason) should take estrogen combined with progesterone to prevent cancer of the lining of the uterus (endometrial cancer).

ALTERNATIVES TO HORMONE THERAPY

There are other medicines that can help with mood swings, hot flashes, and other symptoms. These include:

  • Antidepressants, including paroxetine (Paxil), venlafaxine (Effexor), bupropion (Wellbutrin), and fluoxetine (Prozac)
  • A blood pressure medicine called clonidine
  • Gabapentin, a seizure drug that also helps reduce hot flashes

DIET AND LIFESTYLE CHANGES

Lifestyle steps you can take to reduce menopause symptoms include:

Diet changes:

  • Avoid caffeine, alcohol, and spicy foods.
  • Eat soy foods. Soy contains estrogen.
  • Get plenty of calcium and vitamin D in food or supplements.

Exercise and relaxation techniques:

  • Get plenty of exercise.
  • Do Kegel exercises every day. They strengthen the muscles of your vagina and pelvis.
  • Practice slow, deep breathing whenever a hot flash starts to come on. Try taking 6 breaths a minute.
  • Try yoga, tai chi, or meditation.

Other tips:

  • Dress lightly and in layers.
  • Keep having sex.
  • Use water-based lubricants or a vaginal moisturizer during sex.
  • See an acupuncture specialist.

Possible Complications

Some women have vaginal bleeding after menopause. This is often nothing to worry about. However, you should tell your provider if this occurs. It may be an early sign of other health problems, including cancer.

Decreased estrogen levels have been linked with some long-term effects, including:

  • Bone loss and osteoporosis in some women
  • Changes in cholesterol levels and greater risk of heart disease

When to Contact a Medical Professional

Call your provider if:

  • You are spotting blood between periods
  • You have had 12 consecutive months with no period and vaginal bleeding or spotting begins again suddenly (even a small amount of bleeding)

Prevention

Menopause is a natural part of a woman's development. It does not need to be prevented. You can reduce your risk of long-term problems such as osteoporosis and heart disease by taking the following steps:

  • Control your blood pressure, cholesterol, and other risk factors for heart disease.
  • DO NOT smoke. Cigarette use can cause early menopause.
  • Get regular exercise. Resistance exercises help strengthen your bones and improve your balance.
  • Talk to your provider about medicines that can help stop further bone weakening if you show early signs of bone loss or have a strong family history of osteoporosis.
  • Take calcium and vitamin D.

References

ACOG Practice Bulletin No. 141: management of menopausal symptoms. Obstet Gynecol. 2014;123(1):202-16. PMID: 24463691 www.ncbi.nlm.nih.gov/pubmed/24463691.

Brunner RL, Aragaki A, Barnabei V, et al. Menopausal symptom experience before and after stopping estrogen therapy in the Women's Health Initiative randomized, placebo-controlled trial. Menopause. 2010;17(5):946-54. PMID: 20505547 www.ncbi.nlm.nih.gov/pubmed/20505547.

Lobo R. Menopause and care of the mature woman. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Elsevier Mosby; 2012:chap 14.

Management of osteoporosis in postmenopausal women: 2010 position statement of the North American Menopause Society. Menopause. 2010;17(1):25-54. PMID: 20061894 www.ncbi.nlm.nih.gov/pubmed/20061894.

Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. Menopause. 2013;20(9):888-902. PMID: 23985562 www.ncbi.nlm.nih.gov/pubmed/23985562.

Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013;310(13):1353-68. PMID: 24084921 www.ncbi.nlm.nih.gov/pubmed/24084921.

Moyer VA; U.S. Preventive Services Task Force. Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;158(9):691-6. PMID: 23440163 www.ncbi.nlm.nih.gov/pubmed/23440163.

North American Menopause Society. The 2012 hormone therapy position statement of: The North American Menopause Society. Menopause. 2012;19(3):257-71. PMID: 22367731 www.ncbi.nlm.nih.gov/pubmed/22367731.

Skaznik-Wikiel ME, Traub ML, Santoro N. Menopause. In: Jameson JL, De Groot LJ, de Krester DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 135.

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